A Field Guide To Medicare And Medicaid, And How They Could Change

Twenty-four million people stand to lose health care under the House Republican plan to replace the Affordable Care Act, according to the nonpartisan Congressional Budget Office. The overhaul would also cut $337 billion from the federal budget deficits by 2026, in part, due to changes to Medicaid.

Medicaid covers health care for more than 70 million low-income Americans, including the 11 million that were added after the program's expansion under the ACA. On the other hand, Medicare is the program that helps support 57 million people, many older or with disabilities. Both are expensive and subject to debate.

Here & Now's Meghna Chakrabarti talks about both programs with Joan Alker (@JoanAlker1), executive director of the Center for Children and Families at the Georgetown University Health Policy Institute.

On what Medicaid is

"So Medicaid is a really important part of our health care system. It serves around 70 million Americans. The largest group of folks on Medicaid are children, and about 40 percent of children now in this country are on Medicaid. It also serves seniors and people with a disability in nursing homes — because Medicare doesn't cover that — as well as other low-income parents, families and people with disabilities."

On the significance of 40 percent of American children being on Medicaid

"We're getting close to that number, yes. And the other thing I failed to mention is that pregnant women are a really important population, and in many states, about half of births today are covered by Medicaid. So this program is critical to support our health care system, for kids, all the way through seniors in nursing homes."

On how children and pregnant women might be impacted by the GOP health plan

"Well this is a real sleeper issue that has not gotten enough attention. But the Republican proposal is an extremely radical restructuring of the way the Medicaid program has worked for over 50 years. They are intending to change the financing system, and cap and cut the Medicaid program. So what this will mean is that, today, states can be sure they have a strong federal partner, but they won't have that in the future and that's why [the American Health Care Act] is actually so very concerning for children."

On whether the federal government will remain a partner for states when it comes to Medicaid costs

"There's a complicated formula in the bill, and once the state reaches its cap on spending, then the federal government will not commit any additional funds, and that's what's such a radical change, because we know what's certain in life is the uncertain and that's particularly true when it comes to health care. We know there will be a new virus, like Zika or HIV/AIDS. We know things like the opioid abuse epidemic happen, and we know that there will be new treatments. And states will no longer have the federal government as the partner they've had for the past 50 years."

"The Republican proposal is an extremely radical restructuring of the way the Medicaid program has worked for over 50 years."

Joan Alker

On analysts who say the federal government matching states' Medicaid costs is one reason why health care costs have increased 

"...I think that's a flawed analysis, because we certainly do have a problem with growing costs on our health care system. But that's not Medicaid's fault. That's because we have issues like drug prices that are being jacked up unnecessarily, and that cuts across the health care system. And in fact, we serve a lot more people on Medicaid than we do on Medicare. But the overall cost is less. So Medicaid is an efficient program, and any cuts will definitely result in folks losing access to either coverage or services they need."

On the Affordable Care Act's expansion of Medicaid

"So this was a key part of the way in which the Affordable Care Act reduced the number of uninsured people, even though it too has gotten less attention. But the Supreme Court made this optional. So we saw 31 states and D.C. pick up this option. This is intended to cover both parents who are not the very poorest parents, but still very poor parents, as well as adults who don't currently have a child living in the home with them. So we've seen this be a really important driver of reduction in the uninsured rate. It also helps states to address needs in their mental health and substance abuse systems, and overall has been a very successful part of the Affordable Care Act."

On how the GOP health plan might impact those who benefitted from Medicaid expansion

"So under the new proposal — and there's a lot of discussion about this — but the bill as it currently stands, this starts to get rolled back in 2020, and essentially only folks who are continuously covered would still get the current federal funding level. So over time, we would expect to see this program whither on the vine."

On what Medicare is, and who is eligible for it

"So Medicare covers about 57 million people. Most of those are seniors, some of them are people with disabilities. And, as everybody knows, once you turn 65 you're eligible to be on the Medicare program. And that speaks to one key difference between Medicare and Medicaid which is, Medicare is run by the federal government, whereas Medicaid is run by the 50 states. And as a result, Medicare, I think, is much better understood by folks. And like I said, everybody knows, when you turn 65 you get on Medicare. As opposed to kind of a more patchwork system that we have in Medicaid."

On how Medicare is funded compared to Medicaid

"Medicare is funded just through federal funds. Currently, this year was $692 billion. Medicaid is a combination of federal and state funds, and even though Medicaid serves fewer people, its total spending — including federal and state funds — was $532 billion. So you can see that Medicaid is actually spending quite a bit less per person than Medicare. But there is one little wrinkle here. There are some folks who are on both programs — Medicaid, Medicare, low-income seniors — because in Medicare, you do have some cost sharing, some deductibles and copays, that can be very hard to reach for folks who are very low income. So Medicaid comes in and picks up some of that cost sharing. ...Another important feature of Medicare is that it covers hospital services. We have the Part D drug program, outpatient services. But it does not cover long-term care."

On whether there are concerns about Medicare's long-term viability, as more Americans turn 65

"Yes I think that's true. And we also have folks with longer life expectancies So this is really a challenge, both for Medicare and Medicaid, because the older people get the more health care services they consume. And this is one of the problems — sorry to keep diverting back to Medicaid — but if you cap the Medicaid program, and we have the aging of the population, this is going to create a real, very difficult challenge down the road for states as the population ages and those long-term care services, we're going to see a real crunch ahead if this proposal goes through."

On whether the GOP health plan will impact Medicare

"No, it really doesn't affect Medicare directly, although it does affect some of the financing mechanisms, when the Affordable Care Act did help to protect the life of the Medicare trust fund. But in terms of the beneficiary's experience of the program, it does not affect that."

This conversation is part of a weeklong series on health insurance and the American Health Care Act, the Republican plan to repeal and replace the Affordable Care Act. You can find links to the rest of our stories below.